- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $147.91 / $147.91
| Professional | | $102.33 | $147.91 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $42.66 / $42.66
| Professional | 26 | $27.54 | $42.66 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $104.71 / $104.71
| Professional | TC | $74.13 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $169.82 / $269.15
| Professional | | $117.49 | $169.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $52.48 / $83.18
| Professional | 26 | $34.67 | $52.48 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $117.49 / $186.21
| Professional | TC | $77.62 | $117.49 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $144.54 / $380.19
| Professional | | $33.88 | $144.54 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.96 / $42.66 / $120.23
| Professional | 26 | $10.96 | $42.66 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $102.33 / $263.03
| Professional | TC | $22.91 | $102.33 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $56.23 / $190.55
| Professional | | $53.70 | $56.23 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $17.78 / $58.88
| Professional | 26 | $16.22 | $17.78 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $38.90 / $128.82
| Professional | TC | $38.02 | $38.90 | $128.82 |